Third Edition
Foundations of Periodontics for the Dental Hygienist Jill S. Nield-Gehrig, RDH, MA Dean Emeritus, Division of Allied Health & Public Service Education Asheville-Buncombe Technical Community College Asheville, North Carolina
Donald E. Willmann, DDS, MS Professor Emeritus, Department of Periodontics University of Texas Health Science Center at San Antonio Dental School San Antonio, Texas
Acquisitions Editor: Peter Sabatini Product Manager: Kristin Royer Marketing Manager: Allison Powell Editorial Assistant: Rachel Stark Design Coordinator: Teresa Mallon Art Director: Jennifer Clements Manufacturing Coordinator: Margie Orzech Prepress Vendor: SPi Technologies Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Lippincott Williams & Wilkins at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at
[email protected], or via our website at lww.com (products and services). Printed in China Library of Congress Cataloging-in-Publication Data Nield-Gehrig, Jill S. (Jill Shiffer) Foundations of periodontics for the dental hygienist / Jill S. Nield-Gehrig, Donald E. Willmann.—3rd ed. p. ; cm. Includes bibliographical references and index. ISBN 978-1-60547-573-8 (alk. paper) 1. Periodontics. 2. Dental hygienists. I. Willmann, Donald E. II. Title. [DNLM: 1. Periodontics. 2. Dental Hygienists. WU 240] RK361.F675 2011 617.6’32—dc22 2010027962 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the author, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations. The author, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in his or her clinical practice. LWW.com 9 8 7 6 5 4 3 2 1 (these are reprint numbers—the lowest number is deleted by the printer when each reprint is made)
Liability Statement This textbook endeavors to present an evidence-based discussion of periodontology based on information from recent research. Periodontology, however, is a rapidly changing science. The authors, editors, and publisher have made every effort to confirm the accuracy of the information presented and to describe generally accepted practices at the time of publication. However, as new information becomes available, changes in treatment may become necessary. The reader is encouraged to keep up with dental and medical research through the many peer-reviewed journals available to verify information found here and to determine the best treatment for each individual patient. The authors, contributors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, express or implied, with respect to the contents of this publication.
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Contents Contributors
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Preface for Course Instructors Acknowledgments
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PART 1: THE PERIODONTIUM IN HEALTH 1 PERIODONTIUM: THE TOOTH SUPPORTING STRUCTURES 1 Jill Nield-Gehrig and Donald Willmann Tissues of the periodontium 3 Nerve supply, blood supply, and lymphatic system 14 Focus on patients 19 2 MICROSCOPIC ANATOMY OF THE PERIODONTIUM 21 Jill Nield-Gehrig and Donald Willmann Histology of the body’s tissues 23 Histology of the gingiva 27 Histology of root cementum and alveolar bone 39 Focus on patients 43 PART 2: CLASSIFICATION AND TISSUE DESTRUCTION IN PERIODONTAL DISEASES 3 THE PROGRESSION OF PERIODONTAL DISEASE 47 Jill Nield-Gehrig and Donald Willmann The periodontium in health and disease 49 Pathogenesis of bone destruction 57 Periodontal pockets 62 Focus on patients 65 4 CLASSIFICATION OF PERIODONTAL DISEASES AND CONDITIONS 67 Jill Nield-Gehrig and Donald Willmann Introduction to disease classification 68 Classification systems 70 AAP Classification system for periodontal diseases 72 Overview of periodontal diseases 76 5 SEARCH FOR THE CAUSES OF PERIODONTAL DISEASES 81 Sharon Logue Epidemiology: Researching periodontal disease 82 Control and progression of periodontal disease 87 Risk factors for periodontal disease 91 Focus on patients 92 vi
Contents
PART 3: ETIOLOGY OF PERIODONTAL DISEASES 6 ORAL BIOFILMS AND PERIODONTAL INFECTIONS 95 Jill Nield-Gehrig and Donald Willmann Bacteria in the oral environment 97 Bacteria associated with periodontal health and disease 101 The structure and colonization of plaque biofilms 106 Mechanisms of periodontal destruction 115 Control of plaque biofilms 117 Focus on patients 118 7 LOCAL CONTRIBUTING FACTORS 121 Donald Willmann and Jill Nield-Gehrig Introduction to local contributing factors 122 Local factors that increase plaque biofilm retention 123 Local factors that increase plaque biofilm pathogenicity 128 Local factors that cause direct damage 129 Focus on patients 136 8 BASIC CONCEPTS OF IMMUNITY AND INFLAMMATION 137 Jill Nield-Gehrig and Donald Willmann The body’s defense system 139 Leukocyte migration, chemotaxis, and phagocytosis 146 The inflammatory process 148 Focus on patients 154 9 HOST IMMUNE RESPONSE TO PERIODONTAL PATHOGENS 157 Jill Nield-Gehrig and Donald Willmann The role of host response in periodontal disease 158 Pathogenesis of inflammatory periodontal disease 160 Focus on patients 169 10 SYSTEMIC FACTORS ASSOCIATED WITH PERIODONTAL DISEASES 171 Jill Nield-Gehrig and Donald Willmann Systemic risk factors for periodontitis 173 Genetic risk factors for periodontitis 182 Systemic medications with periodontal side effects 186 Focus on patients 191 11 SMOKING AND PERIODONTAL DISEASE 195 Christoph Ramseier, Carol Southard, and Clemens Walter Introduction to smoking and periodontal disease 196 Mechanisms of periodontal disease progression in smokers 198 Smoking cessation 200 Focus on patients 205 12 ETIOLOGIC FACTORS: RISK FOR PERIODONTITIS 209 Jill Nield-Gehrig and Donald Willmann Risk factors for periodontal disease 210 Balance between periodontal health and disease 212 Focus on patients 218
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Contents
PART 4: GINGIVAL DISEASE 13 CLINICAL FEATURES OF THE GINGIVA 223 Rebecca Sroda Clinical features of healthy gingiva 224 Clinical features of gingival inflammation 226 Extent and distribution of inflammation 231 Focus on patients 233
14 DISEASES OF THE GINGIVA 235 Rebecca Sroda Classification of gingival diseases 236 Dental plaque-induced gingival diseases 237 Non–plaque-induced gingival lesions 244 Focus on patients 250
PART 5: PERIODONTITIS 15 CHRONIC PERIODONTITIS 253 Jill Nield-Gehrig and Donald Willmann Classification of periodontitis 254 Chronic periodontitis—The most common form 255 Focus on patients 267
16 AGGRESSIVE PERIODONTITIS 269 Jill Nield-Gehrig and Donald Willmann Aggressive periodontitis—Highly destructive form Focus on patients 276
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17 OTHER PERIODONTAL CONDITIONS 277 Jill Nield-Gehrig and Donald Willmann Periodontitis as a manifestation of systemic disease 278 Necrotizing periodontal diseases 284 Developmental or acquired deformities and conditions 289 Focus on patients 294
18 PERIODONTITIS AS A RISK FACTOR FOR SYSTEMIC DISEASE 297 Jill Nield-Gehrig and Donald Willmann Periodontitis and systemic disease Focus on patients 316
298
PART 6: ASSESSMENT FOR CLINICAL DECISION MAKING 19 CLINICAL PERIODONTAL ASSESSMENT 321 Donald Willmann and Jill Nield-Gehrig Introduction to periodontal assessment 322 The periodontal screening examination 324 The comprehensive periodontal assessment 326 Clinical features that require calculations 336 Focus on patients 340
Contents
20 RADIOGRAPHIC ANALYSIS OF THE PERIODONTIUM 341 William Moore Radiographic appearance of the periodontium 342 Use of radiographs for periodontal evaluation 345 Focus on patients 352
21 NUTRITION AND PERIODONTAL DISEASE 353 Rebecca Sroda The influence of diet and nutrition on the periodontium 354 Nutritional counseling for a healthy periodontium 359 Focus on patients 361
22 BEST PRACTICES FOR PERIODONTAL CARE 365 Carol Jahn What is best practice? 366 The role of evidence-based care in best practice Finding clinically relevant information 372 Lifelong learning skills for best practice 377 Focus on patients 379
368
23 DECISION MAKING DURING TREATMENT PLANNING FOR PATIENTS WITH PERIODONTAL DISEASE 381 Donald Willmann and Jill Nield-Gehrig Decisions related to assigning a periodontal diagnosis 382 Decisions related to treatment sequencing 387 Informed consent for periodontal treatment 389 Focus on patients 392
PART 7: IMPLEMENTATION OF THERAPY 24 NONSURGICAL PERIODONTAL THERAPY 393 Donald Willmann and Jill Nield-Gehrig Overview of nonsurgical periodontal therapy 394 Nonsurgical instrumentation 398 Decisions following nonsurgical therapy 407 Focus on patients 412
25 MOTIVATIONAL INTERVIEWING TO ENHANCE PATIENT MOTIVATION FOR CHANGE 415 Delwyn Catley, Karen Williams, and Christoph Ramseier Introduction to human behavior change 416 Components of motivational interviewing 419 Implications for dental hygiene practice 424 Focus on patients 430
26 PATIENT’S ROLE IN NONSURGICAL PERIODONTAL THERAPY 433 Carol Jahn and Jill Nield-Gehrig Patient self-care 434 Toothbrushing and tongue cleaning
435
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Contents
Interdental care 438 Focus on patients 447
27 SUPRAGINGIVAL AND SUBGINGIVAL IRRIGATION 449 Carol Jahn Patient-applied home irrigation 450 Professional subgingival irrigation 458 Focus on patients 460 28 CHEMICAL AGENTS IN PERIODONTAL CARE 463 Donald Willmann and Jill Nield-Gehrig Introduction to chemical agents in plaque biofilm control 464 Use of systemic antibiotics to control bacterial plaque biofilm 467 Use of topically delivered chemical agents 470 Focus on patients 479 29 HOST MODULATION 483 Donald Willmann and Jill Nield-Gehrig Introduction to the concept of host modulation 484 Host modulation as part of comprehensive periodontal management 488 Focus on patients 489 30 PERIODONTAL SURGICAL CONCEPTS FOR THE DENTAL HYGIENIST 493 Donald Willmann and Jill Nield-Gehrig Introduction to periodontal surgery 495 Understanding the periodontal flap 503 Description of common types of periodontal surgery 507 Biological enhancement of surgical outcomes 535 Management following periodontal surgery 537 Focus on patients 549 31 MAINTENANCE FOR THE PERIODONTAL PATIENT 555 Donald Willmann and Teresa Butler Duncan Introduction to periodontal maintenance 557 Procedures and planning for periodontal maintenance 560 Disease recurrence and patient compliance 565 Root caries as a complication during periodontal maintenance 569 Focus on patients 575 32 MAINTENANCE FOR THE DENTAL IMPLANT PATIENT 579 Archie Jones Anatomy of the dental implant 580 Peri-implant disease 584 Maintenance of dental implants 586 Focus on patients 594 PART 8: OTHER ASPECTS OF PERIODONTAL THERAPY 33 PERIODONTAL EMERGENCIES 597 Donald Willmann and Jill Nield-Gehrig Abscesses of the periodontium 598 Necrotizing periodontal diseases 606
Contents
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Primary herpetic gingivostomatitis 610 Focus on patients 613
34 DOCUMENTATION AND INSURANCE REPORTING OF PERIODONTAL CARE 615 Dianne Glasscoe Watterson Legal issues in the provision and documentation of care 616 Documentation of periodontal care 618 Computer-based patient records 623 Insurance codes for periodontal treatment 625 Focus on patients 629
35 FUTURE DIRECTIONS FOR MANAGEMENT OF PERIODONTAL PATIENTS 631 Donald Willmann and Jill Nield-Gehrig Diagnostic technology for periodontal diseases 632 Periodontal disease/systemic disease connection 633 Protocols for maintaining dental implants 635 Treatment modalities in periodontal care 635
PART 9: PATIENT CASES 36 COMPREHENSIVE PATIENT CASES 641 Donald Willmann, Richard Foster, and Jill Nield-Gehrig
Case 1: Mr. Karn 642 Case 2: Mr. Wilton 649 Case 3: Mrs. Sandsky 657 PART 10: INTERNET RESOURCES Internet Resources for students and faculty are available on the companion website at http://thePoint.lww.com
37 PATIENT CASES: RADIOGRAPHIC ANALYSIS John Preece
38 PERIODONTAL RESOURCES IN DENTAL LITERATURE AND ON THE INTERNET Jill Nield-Gehrig and Donald Willmann Guidelines for reading dental literature Procedure for searching the Internet Periodontal Resources on the Internet
ONLINE STUDENT AND INSTRUCTOR RESOURCES Margaret Lemaster, Erin Waugh, Rebecca Sroda, Donald Willmann, and Jill Nield-Gehrig Glossary Index
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Contributors Ralph M. Arnold, DDS Associate Professor, Retired Department of Periodontics University of Texas Health Science Center at San Antonio San Antonio, Texas Elizabeth Carr, RDH, BS Department of Dental Hygiene University of Mississippi Medical Center Jackson, Mississippi Delwyn Catley, PhD Associate Professor and Director of Clinical Training Department of Psychology University of Missouri – Kansas City Kansas City, Missouri Teresa Butler Duncan, RDH, BS Department of Dental Hygiene School of Health Related Professions The University of Mississippi Medical Center Jackson, Mississippi Richard Foster, DMD Dental Director Guilford Technical Community College Jamestown, North Carolina Carol A. Jahn, BSDH, MS Manager, Professional Education & Communications WaterPik Technologies, Inc. Fort Collins, Colorado Archie A. Jones, MBA, DDS Associate Professor Department of Periodontics University of Texas Health Science Center at San Antonio San Antonio, Texas
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Margaret Lemaster, BSDH, MS School of Dental Hygiene Old Dominion University Norfolk, Virginia Sharon Logue, RDH, MPH Virginia Department of Health Division of Dental Health Richmond, Virginia Deborah P. Milliken, BS, DMD Professor, Dental Hygiene South Florida Community College Avon Park, Florida William S. Moore, DDS, MS Assistant Professor and Clinic Director Division of Oral & Maxillofacial Radiology Department of Dental Diagnostic Science University of Texas Health Science Center at San Antonio San Antonio, Texas John Preece, DDS, MS Professor, Division of Oral & Maxillofacial Radiology Department of Dental Diagnostic Science University of Texas Health Science Center at San Antonio San Antonio, Texas Christoph A. Ramseier, MAS Dr. Med. Dent. Assistant Professor Department of Periodontology University of Berne, School of Dental Medicine Bern, Switzerland
Carol Southard, RN, MSN Tobacco Cessation Specialist Northwestern Memorial Hospital Wellness Institute Chicago, Illinois Rebecca Sroda, RDH, MS Associate Dean Allied Health South Florida Community College Avon Park, Florida Clemens Walter, DDS Assistant Professor Department of Periodontology, Endodontology, & Cariology University of Basel Dental School Basel, Switzerland Dianne Glasscoe Watterson, RDH, MBA, CEO Professional Dental Management, Inc. www.professionaldentalmgmt.com Frederick, Maryland Karen Williams, RDH, MS, PhD Professor Department of Dental Hygiene and Dental Public Health and Behavioral Sciences University of Missouri – Kansas City Kansas City, Missouri Erin Waugh, BSDH, MS School of Dental Hygiene Old Dominion University Norfolk, Virginia
Reviewers Gail Aamodt, RDH, MS Clinical Coordinator School of Dental Health Science Pacific University Hillsboro, Oregon
Susan Gorman RDH, BS Ed, MEd (C) Director Dental Hygiene Tri-State Institute Birmingham, Alabama
Susan Nichols, RDH, EFDA, BIS Periodontology Instructor Department of Dental Hygiene Owens Community College Toledo, Ohio
Joanna Allaire, BSDH Clinical Assistant Professor Periodontics/Dental Hygiene The University of Texas Dental Branch Houston, Texas
Stephanie Harrison, RDH, MA Director Dental Hygiene Community College of Denver, Denver, Colorado
Amilia Peskir, Dip. DH, BSc Instructor Dental Hygiene John Abbott College Ste. Anne de Bellevue, Québec
Sharon Logue, RDH, MPH Division of Dental Health Virginia Department of Health Richmond, Virginia
Kelli Shaffer, RDH, MA Ed Full-Time Faculty Dental Health Science Pacific University Hillsboro, Oregon
Jean Byrnes-Ziegler, RDH, MS Professor and Program Director Dental Hygiene Harcum College Bryn Mawr, Pennsylvania Elizabeth Di Silvio, RDH, MEd Associate Professor Dental Hygiene Northern Virginia Community College Springfield, Virginia
Susan Long, RDH, EdD Chairman and Professor Dental Hygiene University of Arkansas for Medical Sciences Little Rock, Arkansas
Alla Wheeler, RDH, BA, MPA Professor Dental Hygiene New York University College of Dentistry New York, New York
Marie Gillis, RDH, MS National Dean Dental Programs Education Affiliates Washington, District of Columbia
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Preface for Course Instructors Foundations of Periodontics for the Dental Hygienist, 3rd edition, is written with two primary goals in mind. First and foremost, this textbook focuses on the dental hygienist’s role in periodontics. Our second goal was to develop a book with an instructional design that facilitates the teaching and learning of the complex subject of periodontics—as it relates to dental hygiene practice—without omitting salient concepts or “watering down” the material. Written primarily for dental hygiene students, Foundations of Periodontics for the Dental Hygienist also would be a valuable resource on current concepts in periodontics for the practicing dental hygienist or general dentist.
INSTRUCTOR TEACHING RESOURCES Follow the steps in Box 1 to access the online instructor resources.
Box 1 Accessing Online Instructor Resources 1. Open an internet browser and select: http://thePoint.lww.com 2. Existing users: log on. Skip to step 4 in this list. 3. New users: select “Register a New Account.” Complete all required fields on the online access request form. Select “Submit Adoption Form” button. Once the form is submitted in good order, you will receive an approval notice. U.S. and Canadian educators, please allow three business days for a reply. Note: the access codes that come in the textbook provide students with access to the full online text and chapter review questions only. 4. Locate “Foundations of Periodontics for the Dental Hygienist.” Select “Instructor Resources.”
TEXTBOOK FEATURES The third edition of Foundations of Periodontics for the Dental Hygienist has many features designed to facilitate learning and teaching. 1. Module Overview and Outline. Each module begins with a concise overview of the module content. The module outline makes it easier to locate material within the module. The outline provides the reader with an organizational framework with which to approach new material. 2. Learning Objectives and Key Terms. Learning objectives assist students in recognizing and studying important concepts in each chapter. Key terms are listed at the beginning of each chapter. One of the most challenging tasks for any student is learning a whole new dental vocabulary and gaining the confidence to
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Preface for Course Instructors
use new terms with accuracy and ease. The key terms list assists students in this task by identifying important terminology and facilitating the study and review of terminology in each chapter. Terms are highlighted and clearly defined within the chapter. 3. Instructional Design • Each chapter is subdivided into sections to help the reader recognize major content areas. • Chapters are written in an expanded outline format that makes it easy for students to identify, learn, and review key concepts. • Material is presented in a manner that recognizes that students have different learning styles. Hundreds of illustrations and clinical photographs visually reinforce chapter content. • Chapter content is supplemented in a visual format with boxes, tables, and flow charts. 4. Focus on Patients. The “Focus on Patients” items allow the reader to apply chapter content in the context of clinical periodontal care. The cases provide opportunities for students to integrate knowledge into their clinical work. 5. Chapter Review Questions. Chapter Review Questions provide a quick review of chapter content. The chapter review questions are available to students on the companion website at http://thePoint.lww.com. 6. Internet Resources in Periodontics. Chapter 38 provides an extensive list of Internet resources. Students should be encouraged to develop skills in online information gathering. With the rapid explosion of knowledge in the dental and medical sciences, a student can no longer expect to learn everything that he or she needs to know, now and forever, in a few years of professional training. Students must learn how to retrieve accurate information quickly from reliable Internet sites, such as MEDLINE. Chapter 38, Periodontal Resources in Dental Literature and on the Internet, is available to students on the companion website at http;//thePoint. lww.com. 7. Comprehensive Patient Cases. Chapter 36 presents three fictitious patient cases. Patient assessment data pertinent to the periodontium challenge the student to interpret and use the information in periodontal care planning for the patient. 8. Glossary. The glossary provides quick assess to common periodontal terminology.
CONTENT SEQUENCING The book is divided into nine major content areas: Part 1: The Periodontium in Health Part 2: Classification and Tissue Destruction in Periodontal Diseases Part 3: Etiology of Periodontal Diseases Part 4: Gingival Disease Part 5: Periodontitis Part 6: Assessment for Clinical Decision Making Part 7: Implementation of Therapy
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Acknowledgments
Part 8: Other Aspects of Periodontal Therapy Part 9: Patient Cases Part 10: Internet Resources Foundations of Periodontics for the Dental Hygienist, 3rd edition, strives to present the complex subject of periodontics in a reader-friendly manner. The authors greatly appreciate the comments and suggestions from educators and students. It is our sincere hope that this textbook will help students and practitioners alike to acquire knowledge that will serve as a foundation for the prevention and management of periodontal diseases. Jill S. Nield-Gehrig, RDH, MA Donald E. Willmann, DDS, MS
Acknowledgments It is a great pleasure to acknowledge the following individuals whose assistance was indispensable to this third edition: • Charles D. Whitehead and Holly R. Fischer, MFA the highly skilled medical illustrators, who created all the wonderful illustrations for the book. • Kevin Dietz, a colleague and friend for his vision and guidance for all three editions of this book. • And with great thanks to our wonderful team at Lippincott Williams & Wilkins without whose expertise and support this book would not have been possible: John Goucher, Kristin Royer, Peter Sabatini, and Jennifer Clements.
Jill S. Nield-Gehrig, RDH, MA Donald E. Willmann, DDS, MS
Chapter 1
Periodontium: The ToothSupporting Structures Section 1
Tissues of the Periodontium
3
The Gingiva Periodontal Ligament Root Cementum Alveolar Bone
Section 2
Nerve Supply, Blood Supply, and Lymphatic System
14
Nerve Supply to the Periodontium Blood Supply to the Periodontium Lymphatic System and the Periodontium
Section 3
Focus on Patients
19
Learning Objectives • List and recognize the clinical features of periodontal health. • Describe the function that each tissue serves in the periodontium, including the gingiva, periodontal ligament, cementum, and alveolar bone. • In a clinical setting, identify the following anatomical areas of the gingiva in the oral cavity: free gingiva, gingival sulcus, interdental gingiva, and attached gingiva. • Identify the tissues of the periodontium on an unlabeled drawing depicting the periodontium in cross section. • In a clinical setting, identify the following boundaries of the gingiva in the oral cavity: gingival margin, free gingival groove, and mucogingival junction. If the free gingival groove is not visible clinically, determine the apical boundary of the free gingiva by inserting a probe to the base of a sulcus on an anterior tooth. • In a clinical setting, identify the free gingiva on an anterior tooth by inserting a periodontal probe to the base of the sulcus. • In a clinical setting, contrast the coral pink tissue of the attached gingiva with the darker, shiny tissue of the alveolar mucosa. • In a clinical setting, use compressed air to detect the presence or absence of stippling of the attached gingiva. • Identify the alveolar process (alveolar bone) on a human skull.
Gingiva
Tissues of the Periodontium
Cementum Periodontal Ligament Alveolar Bone
Sulcus Gingival fibers Crest of alveolar bone Periodontal ligament Alveolar bone
Alveolar mucosa Mucogingival junction Attached gingiva Free gingiva Interdental gingiva
Gingival margin Free gingival line
Free gingiva
Attached gingiva Mucogingival junction
Alveolar mucosa
Alveolar mucosa
Attached gingiva
Mucogingival junction
A
B
Attached gingiva
Stippling
Contact area Facial papilla
Contact area Facial papilla Col
Lingual papilla
Proximal view
Col
Lingual papilla
Dentin
tum
CDW
Cemen
cket to o th s o Bone of
Periodontal ligament
Alveolar process Ramus
Body Scalloped bone contour
Alveolar bone proper
Cortical bone
Cancellous bone
Cortical bone
Cancellous bone Mandibular canal
Alveolar process
Body of mandible
Trigeminal nerve (V)
Infraorbital nerve
Superior alveolar nerves: Posterior Middle Anterior
Buccal nerve Lingual nerve Inferior alveolar nerve Lateral View
Mental nerve
Nasal branch of superior alveolar nerve Greater palatine nerve Internal branch of infraorbital nerve Nasopalatine nerve
CNS A
C A Mesencephalic sensory neurons of the trigeminal nerve
B TG
B Motor nucleus of the trigeminal C Sensory nucleus of the trigeminal D Spinal sensory trigeminal nucleus E Fibers of the masticatory musculature
D
E
TG Trigeminal ganglion (Gasserian ganglion) with its three branches: opththalmic, maxillary, and mandibular
CNS CNS Central nervous system
Greater palatine artery
Infraorbital artery
Buccal artery Maxillary artery
Posterior superior alveolar artery
Inferior alveolar artery
Mental artery
Facial artery Lingual artery W D C
External carotid artery
Sublingual artery Submental artery
Gingival anastomosis of vessels Periodontal ligament arteries Rami perforantes Interseptal artery Dental artery Inferior alveolar artery CDW
Dentogingival plexus
Subepithelial plexus with capillary loops
Supraperiostial artery Intraseptal artery CDW
Complex network of periodontal ligament vessels
Deep cervical nodes Jugulodigastric node Deep cervical nodes
Submental nodes Submandibular nodes
Chapter 2
Microscopic Anatomy of the Periodontium Section 1
Histology of the Body’s Tissues
23
Microscopic Anatomy of a Tissue Microscopic Anatomy of Epithelial Tissue Microscopic Anatomy of Connective Tissue Epithelial–Connective Tissue Boundary Epithelial Cell Junctions
Section 2
Histology of the Gingiva
27
Microscopic Anatomy of Gingival Epithelium Why Teeth Need a Junctional Epithelium Attachment of the Cells of the Junctional Epithelium Microscopic Anatomy of Gingival Connective Tissue
Section 3
Histology of the Root Cementum and Alveolar Bone
39
Microscopic Anatomy of Cementum Microscopic Anatomy of Alveolar Bone
Section 4
Focus on Patients
43
Learning Objectives • Define the term epithelial tissue and describe its function in the body. • List and define the layers that comprise the stratified squamous epithelium of the skin. • Define keratin and describe its function in the epithelium. • Define the term cell junction and describe its function in the epithelial tissues. • Compare and contrast the terms desmosome and hemidesmosome. • Describe the epithelium–connective tissue interface found in most tissues of the body, such as the interface between the epithelium and connective tissues of the skin. • Describe the function of connective tissue in the body. • List and recognize the histologic features of periodontal health. • List and define the layers that comprise the stratified squamous epithelium of the gingiva.
Fibroblast Extracellular matrix Mast cell Collagen fiber bundle Macrophage Plasma cell Elastic fiber B-lymphocyte
Epithelium
Connective tissue
Epithelium Epithelial ridge Wavy tissue boundary Connective tissue
Connective tissue papilla
CDW
Desmosome Epithelial cells
Basal lamina
Connective tissue
Hemidesmosome
En am el
Den tin
SE CEJ
JE
Cementum Connective tissue
Bone
OE
A KL GL PL
B
BL
SL PL BL B C Tooth PL BL
C
A
OE
Enamel
Keratinized
SE
Dentin
Nonkeratinized
Basal cell layer of epithelium
JE Nonkeratinized Connective tissue
Hemidesmosomes
Desmosomes
Enamel
Internal basal lamina Cementum
External basal lamina Gingival fibers
Hemidesmosome Internal basal lamina
100 nm
Tooth surface
Epithelial cell sheet
Basal lamina Macrophage
Capillary
Gel-like ground substance Co
llag
bers en fi
Fibroblast Elastin fibers
Lymphocyte CDW
Enamel
Sulcus
Sulcular epithelium
Junctional epithelium Supragingival fibers
Bone Cementum
Gingival sulcus Junctional epithelium
CEJ
Soft tissue attachment
Alveolar bone
IG
C
TG IC C
TS
D G DG
IP
AG PG
Periodontal ligament Alveolar bone
Periodontal ligament Cementum
A
Periodontal ligament Alveolar bone
Periodontal ligament Cementum
B
Periodontal ligament Alveolar bone
C
Periodontal ligament Cementum
Alveolar crest fibers Horizontal fibers Interradicular fibers Oblique fibers Apical fibers
Dentin
Cemen
bone
tum
A lv e o la r
Periodontal ligament
Sharpeys Fibers
AC
C
Enamel
Cementum
Dentin
1
2
3
Chapter 3
The Progression of Periodontal Disease Section 1
The Periodontium in Health and Disease
49
Three Basic States of the Periodontium Periodontium in Health Gingivitis—Reversible Tissue Damage Periodontitis—Permanent Tissue Destruction
Section 2
Pathogenesis of Bone Destruction
57
Changes in Alveolar Bone Height in Disease Patterns of Bone Loss in Periodontitis
Section 3
Periodontal Pockets
62
Characteristics of Periodontal Pockets Pocket Formation
Section 4
Focus on Patients
65
Learning Objectives • Define the term pathogenesis. • Define the term periodontal disease and contrast it with the term periodontitis. • Name and define the two types of periodontal disease. • Compare and contrast the clinical and histologic characteristics of the periodontium in health, gingivitis, and periodontitis. • In the clinical setting, point out to your clinical instructor visible clinical signs of health, gingivitis, and/or periodontal disease. • In the clinical setting, point out to your clinical instructor any visible clinical signs of periodontal disease. Using a periodontal probe, measure the depth of the sulci or pockets on the facial aspect of one sextant of the mouth. Using the information gathered visually and with the periodontal probe, explain whether this patient’s disease is gingivitis or periodontitis. • Describe the sequential development of inflammatory periodontal disease. • Describe the position of the crest of the alveolar bone in gingivitis. • Describe the position of the junctional epithelium in health, gingivitis, and periodontitis.
Health
Basic States of the Periodontium
Gingivitis
Periodontitis
Health Clinical
Hi stol ogi cal
Clinical Picture of Health
Healthy Sulcus
Pink Firm No bleeding
J E coronal to C E J Supragingival fibers intact Alveolar bone intact Periodontal ligament intact
Gingivitis (Reversible Damage)
Clinical
Hi stol ogi cal
Clinical Picture of Gingivitis
Gingival Pocket
Red Swollen Bleeding likely
J E at C E J Supragingival fiber destruction Alveolar bone intact Periodontal ligament intact
Periodontitis (Permanent Destruction)
Clinical
Hi stol ogi c a l
Clinical Picture of Periodontitis
Periodontal Pocket
Pink or purplish Swollen or fibrotic Bleeding
J E on cementum Supragingival fiber destruction Alveolar bone destruction Periodontal ligament destruction
Gingival sulcus Oral epithelium Junctional epithelium
Gingival connective tissue Alveolar bone Cementum Periodontal ligament
CEJ Probing depth Junctional epithelium
Gingival pocket Epithelial ridges Swollen tissue Junctional epithelium Gingival fiber destruction
Alveolar bone intact Cementum intact Periodontal ligament intact
CEJ Probing depth Junctional epithelium
Epithelial ridges Swollen tissue Periodontal pocket Gingival fiber destruction, collagen destruction in connective tissue Bone and periodontal ligament destruction
CEJ Probing depth Junctional epithelium
Intact transseptal fibers
Gingival margin
Crest of bone
Gingival margin
Crest of bone
Gingival margin
Crest of bone
Tooth #1
Tooth #2
B
A
Tooth #1
A
Tooth #2
B
1
1
From gingival connective tissue
Into connective tissue sheaths of blood vessels
2 Into periodontal ligament space
3
2
3
Into the alveolar bone
Into alveolar bone
Into the periodontal ligament space
A
B
A
B
C
D
A
B
Pocket base
Facial
Pocket base
Mesial
Lingual
Distal
CEJ Probing depth Junctional epithelium
A
CEJ
CEJ
Probing depth
Probing depth
Junctional epithelium
Junctional epithelium
B
CEJ
CEJ
Probing depth
Probing depth
Junctional epithelium
Junctional epithelium
Chapter 4
Classification of Periodontal Diseases Section 1
Introduction to Disease Classification
68
Major Diagnostic Categories of Periodontal Disease Terminology: Periodontal Disease Versus Periodontitis
Section 2
Classification Systems
70
The 1989 Classification of Inflammatory Periodontal Diseases The 1999 AAP Classification of Periodontal Diseases and Conditions Comparing the 1989 and 1999 Classification Systems
Section 3 Section 4
AAP Classification System for Periodontal Disease
72
Overview of Periodontal Diseases
76
Gingival Diseases Periodontitis
Learning Objectives • List, describe, and differentiate the various periodontal diseases according to the 1999 classification system established by the American Academy of Periodontology. • Define and contrast the terms gingival disease, periodontal disease, and periodontitis. • Define and contrast the terms plaque-induced gingival diseases and non–plaque-induced gingival lesions. • Define and contrast the terms chronic periodontitis and aggressive periodontitis.
Key Terms Classification Gingivitis Periodontitis Periodontal disease American Academy of Periodontology Plaque-induced gingival diseases Non–plaque-induced gingival lesions Chronic periodontitis
Aggressive periodontitis Periodontitis as a manifestation of systemic diseases Necrotizing periodontal diseases Tissue necrosis Periodontal abscess Periodontitis associated with endodontic lesions
P ER I ODONTA L DI S EA S E
1
2
G ING IV I T I S
PERIODONTITIS
Reversible tissue damage
Irreversible tissue damage
1
no
Is there inflammation?
yes 2
HEALTH
no GINGIVITIS
Is there loss of attachment?
yes
PERIODONTITIS
Chapter 5
Search for the Causes of Periodontal Disease Section 1 Section 2
Epidemiology: Researching Periodontal Disease
82
Control and Progression of Periodontal Disease
87
Control of Periodontal Disease Progression of Periodontal Disease
Section 3
Risk Factors for Periodontal Disease
91
Section 4
Focus on Patients
92
Learning Objectives • Describe variables associated with periodontal disease that an epidemiologist might include in a research study. • Define prevalence and incidence as measurements of disease within a population. • Discuss historical and current theories associated with the progression of periodontal disease. • Describe how clinical dental hygiene practice can be affected by epidemiological research.
Key Terms Epidemiology Incidence Prevalence Disease progression
Periodontal pathogens Intermittent disease progression Risk factors
Why does one part of the population have less periodontal disease than another?
How prevalent is periodontal disease in the population?
What genetic characteristics does the population have to increase their risk for periodontal disease?
Questions an epidemiologist might ask about periodontal disease...
What life style behaviors does the population have to increase their risk of periodontal disease?
What is the cause of periodontal disease?
1%
4%
70%
14-17
18-34
35-44
Y E A RS O F AG E
Healthy Periodontal disease
90%
45-80
Prevalence of Loss of Attachment of 4mm or More by Age* and Race/Ethnicity
80 70
67.5
PERCENT
60
55.7 52.6
50
46.2 38.6
40
33.5 28.1
30 20 10 0
27.0
18.2 6.1 20-29
30-39
40-49
50-59
60-69
70-79
80-90
*Age standardized to the year 2000 US population
80
99.2 96.5 97.8
NonNon- MexicanHispanic Hispanic American White Black
Percentage of Adults With 21 or More Teeth by Age and Race/Ethnicity 96.0 99.2
70
81.5
Non-Hispanic White
85.2 76.8
Non-Hispanic Black
PERCENT
60
67.8
50
57.5
Mexican-American
54.2
40
46.3
44.7 35.0
30
32.2
31.5
32.2
23.3
20
18.4 11.3
10 2.1
0
20-29
30-39
40-49
50-59
60-69
70-79
80 and Older
CALCULUS DEPOSITS
TOOTH
DISEASE
BACTERIA
BACTERIA
TOOTH
HOST RESPONSE TO BACTERIAL INFECTION
DISEASE
DISEASE
D IS EAS E PR OG RE S S IO N
worse
better
T I M E
D I SEA SE P R O G R ESSI O N
worse
better T I M E
Chapter 6
Oral Biofilms and Periodontal Infections Section 1
Bacteria in the Oral Environment
97
Characteristics of Bacteria Biofilms: Bacterial Communities
Section 2
Bacteria Associated with Periodontal Health and Disease
101
Species Capable of Colonizing the Mouth Microorganisms Associated with Specific Periodontal States Current Suspected Periodontal Pathogens
Section 3
The Structure and Colonization of Plaque Biofilms
106
The Complex Structure of Dental Plaque Biofilms Bacterial Colonization and Succession Microbial Complexes and Attachment Zones
Section 4
Mechanisms of Periodontal Destruction
115
Section 5
Control of Plaque Biofilms
117
Section 6
Focus on Patients
118
Learning Objectives • Define the terms innocuous, pathogenic, virulent, Gram-positive, and Gram-negative. • Recognize that not all bacteria are equally capable of causing periodontal disease. • Define the term biofilm and explain the advantages to a bacterium of living in a biofilm. • Name three everyday examples of biofilms in the environment. • Name the three bacteria designated by The World Workshop in Periodontology as periodontal pathogens. • Identify bacteria associated with health, gingival diseases, and periodontitis. • Describe how the numbers of bacteria vary from health to disease in the periodontium. • Name and describe the components of the biofilm structure. • Given a drawing of a mature biofilm, label the following: bacterial microcolonies, fluid channels, extracellular slime layer, acquired pellicle, and tooth surface.
Gram positive Peptidoglycan
+
Cytoplasmic membrane Cytoplasm with organelles Genome Ribosome
er
,M FA
Plasmid
H RF
A
isc
h
Attachment pili
Outer membrane Periplasmatic space Peptidoglycan Cytoplasmic membrane
Cytoplasm with organelles
Flagella
Fimbriae
– B
Gram negative
Contact lens case
Tooth Rocks in a stream
Artificial hip implant
On glass sides of a fish tank
Attachment 1
Growth 2
Detachment 3
Gram positive
Facultative anaerobes Cocci
Rods
+
Gram negative
Obligate anaerobes
Facultative anaerobes
Streptococcus Peptostreptococcus –P. micros • Pm –S. anginosus (S. milleri) Peptococcus –S. mutans –S. sanguis • Ss –S. oralis –S. mitis –S. intermedius Actinomyces –A. naeslundii • An –A. viscosus • Av –A. odontolyticus –A. israelii
Eubacterium –E. nodatum • En –E. saburreum –E. timidum –E. brachy –E. alactolyticum
Propionibacterium Bifidobacterium –B. dentium Rothia –R. dentocariosa Lactobacillus –L. oris –L. acidophilus –L. salivarius –L. buccalis
Spirochetes and mycoplasms
Eukaryotes
Obligate anaerobes Veillonella –V. parvula
Neisseria Branhamella
Aggregatibacter –A. actinomycetemcomitans • Aa
Porphyromonas –P. gingivalis • Pg –P. endodontalis
Capnocytophaga –C. ochracea –C. gingivalis –C. sputigena
Prevotella –P. intermedia • Pi –P. nigrescens –P. denticola –P. loescheii –P. oris –P. oralis
Campylobacter –C. rectus • Cr –C. curvus –C. showae Eikenella –E. corrodens • Ec Haemophilus –H. aphrophilus –H. segnis
Tannerella –T. forsythia
Selenemonas –S. sputigena –S. noxia
Treponema sp. –T. denticola • Td –T. socranskii –T. pectinovorum –T. vincentii Entamoeba
• Tf
Fusobacterium –F. nucleatum • Fn –F. periodonticum
Spirochetes of ANUG
Mycoplasm –M. orale –M. salivarium –M. hominis
Candida –C. albicans
–
Trichomonas
+ Rods + Cocci – Rods
+ Rods
– Rods
+ Rods – Cocci
+ Cocci
Health Aerobic and facultative organisms Anaerobic organisms
+ Rods
– Rods
+ Cocci + Rods
+ Cocci
+ Rods – Rods
Gingivitis Periodontits
“I just can’t go with the flow anymore. I’ve been thinking about joining a biofilm!” James Pennington
(Phase 1) (Phase 2)
(Phase 3)
(Phase 4)
Multiplication
Continued growth
(Phase 5)
Flow
Clean surface
Film coating
Binding of single organisms
Mature biofilm
Streamer Root surface
Bacterial microcolony
Acquired pellicle
Extracellular slime layer Void
Bacterial microcolony
Fluid channel
Saliva and GCF
Cell-cell communication
ns
ita
C. sputigena
H. parainfluenzae A. israelii P. loescheii
P. denticola E. corrodens
um at cle nu
V. S. oralis S. sanguinis atypica
P. intermedia
m riu cte ba Eu
S. gordonii
a A. Fusobacterium nucleatum
P. acnes C. gingivalis
m
no
cti
C. ochracea
S. mitis S. oralis
c
m
te
e yc
om
T. denticola
P. gingivalis
S. gordonii A. naeslundii
Early colonizers
S. fleuggei
Late colonizers
Av
Ss
Av
Ss
Acquired pellicle
A
Ss
Av
Ss Av
Ss
Av
Ss
Acquired pellicle
B
Fn Pi Ss
Pi
Fn Av
Av
Ss
Ss
Av
Ss
Acquired pellicle
C
Cg Cg Ai Fn Ss
Acquired pellicle
D
Pi
Fn Av
Ai
Pg
Pi Ss Ss
Av
Av Ss
Actinomyces species
Subgingival Microbial Complexes V. parvula A. odontolyticus
S. mitis S. oralis S. sanguis
C. gracilis
Streptococcus sp. S. gordonii S. constellatus S. intermedius
E. corrodens C. gingivalis C. sputigena C. ochracea C. concisus A. actino. a
C. rectus
P. intermedia P. nigrescens P. micros F. nuc. vincentii F. nuc. nucleatum F. nuc. polymorphum F. periodonticum
P. gingivalis T. forsythia T. denticola E. nodatum
C. showae S. noxia A. actino. b
0 hours
12 weeks 6 hours
Acquired pellicle formation
Bacterial adhesion
Day 7
Supragingival plaque
Plaque maturation
Actinomyces Streptococci
Filamentous bacteria
Well-differentiated subgingival biofilm
Root surface Epithelial lining of periodontic pocket
Acquired pellicle
Chapter 7
Local Contributing Factors Section 1
Introduction to Local Contributing Factors
122
Mechanisms for Increased Disease Risk
Local Factors that Increase Plaque Biofilm Retention
123
Local Factors that Increase Plaque Biofilm Pathogenicity
128
Section 4
Local Factors That Cause Direct Damage
129
Section 5
Focus on Patients
136
Section 2
Section 3
Learning Objectives • Define the terms pathogenicity and local contributing factors. • Identify local etiologic factors that contribute to the retention and accumulation of microbial plaque biofilm. • Explain the meaning of the phrase “pathogenicity of plaque biofilm.” • Identify and differentiate the location, composition, modes of attachment, mechanisms of mineralization, and pathologic potential of supragingival and subgingival calculus deposits. • Describe four local contributing factors that can lead to direct damage to the periodontium. • Describe the role of trauma from occlusion as a contributing factor in periodontal disease.
Key Terms Local contributing factors Disease site Dental calculus Pellicle Morphology Overhanging restoration Palatogingival groove Pathogenicity Plaque biofilm pathogenicity Food impaction Tongue thrusting Mouth breathing Biologic width
Embrasure space Encroaching on the embrasure space Prosthesis Removable prosthesis Trauma from occlusion Primary trauma from occlusion Secondary trauma from occlusion Functional occlusal forces Parafunctional occlusal forces Clenching Bruxism Occlusal adjustment
A
B
Floss
Root
A
B
Gingival sulcus 0.69 mm Junctional epithelium 0.97 mm Biologic width Connective 2.04 mm tissue attachment 1.07 mm Periodontal ligament Bone
Restoration
Restoration
Gingival sulcus
Gingival sulcus
Biologic width
A
Biologic width
B
A
B
Tipping movement
T
A
P
B
C
Chapter 8
Basic Concepts of Immunity and Inflammation Section 1
The Body’s Defense System
139
Introduction to the Immune System Components of the Immune System Cells of the Immune System The Complement System
Section 2
Section 3
Leukocyte Migration, Chemotaxis, and Phagocytosis
146
The Inflammatory Process
148
Major Events in the Inflammatory Response Two Stages of Inflammation
Section 4
Focus on Patients
154
Learning Objectives • Define the term immune system and name its primary function. • Define the term inflammation and name two events that can trigger the inflammatory response. • Name the five classic symptoms of acute inflammation and explain what events in the tissues result in these classic symptoms. • Give an example of a type of injury or infection that would result in inflammation in an individual’s arm. Describe the symptoms of inflammation that the individual would experience. • Compare and contrast acute inflammation and chronic inflammation. • Define the term phagocytosis and describe the steps in this process. • Describe the role of polymorphonuclear leukocytes in the immune system. • Describe the role of macrophages in the immune system. • Contrast the terms macrophage and monocyte. • Describe the role of B lymphocytes in the immune system. • Describe the role of T lymphocytes in the immune system. • Describe the three ways that antibodies participate in the host defense. • Define the term inflammatory mediator. • Define complement system and explain its principle functions in the immune response.
Infectious organisms taking advantage of breaches in the body’s barriers
Infectious organisms
Parasitic infections
an es ted
Self
ncer Ca
Organisms invading and reproducing in the human body as part of their life cycle
Transformation of normal body cells into tumor cells that threaten the body
Toxic substances To released by other xin s organisms or from environmental sources
l sp u n a Tr tiss
Grafts from non-identical donors
Leukocytes
Cells
Lymphocytes
B-cells
Others Phagocytes
T-cells Large granular Mononuclear phagocytes lymphocytes
Neutrophil Granulocyte eosinophil
Helper Cells
Basophil Mast cell
Blood platelets Tissue cells
Soluble Antibodies mediators
Cytokines
Complement factors
Inflammatory mediators
Interferon cytokines
Lysosome Multi-lobed nucleus
Phagosome
Phagosome Lysosome Nucleus
“A.” Monocyte Pseudopodia
Phagosome
Lysosome
“B.” Macrophage
Pseudopodia
Nucleus
B-lymphocytes
Y-shaped antibodies
Lysis
Opsonization
Complement proteins Bacteria
Activation of Inflammatory Response
Clearance of Immune Complexes Ag-Ab complex
Complement receptor
Degranulation Tissue Blood
Target cell Complement proteins
Phagocyte
Extravasation
Phagocyte
Polymorphonuclear leukocyte (PMN)
A Macrophage
B B-lymphocyte/ Plasma cell
C T-lymphocytes
D Immunoglobulins IgG, IgM, IgA, IgD, IgE
E Complement System
F
Protein Chemokines Cytokines
A
Fluids
B
C
1 Bacterium becomes attached to membrane evaginations called pseudopodia
2 Bacterium is ingested, forming phagosome
3 Phagosome fuses with lysosome
4 Lysosomal enzymes digest captured material
5 Digestion products are released from cell
4 Phagocytes destroy bacteria
1 Tissue damage triggers a local increase in Neutrophils and other phagocytes
blood flow and capillary permeability
Bacteria 2 Permeable capillaries allow an influx of fluid (exudate) and cells into tissue
3 Phagocytes migrate to
Exudate (complement, C-reactive protein)
site of inflammation (chemotaxis)
Extravasation Neutrophil Capillary
Tissue Invasion by Bacteria Results in
Injury to the Body Reaction
Body’s Inflammatory Response: Increased blood flow delivers the body’s defensive cells and plasma to the invasion site
Leukocytes and plasma proteins leak from blood vessels into the tissue at the site of infection
Leukocytes fight the invading bacteria
Some tissue destruction occurs in the area surrounding the infection site that is a side-effect of the body’s inflammatory response
Inflammatory Response
HEAT!
REDNESS!
SWELLING!
Bacterial infection of 2 weeks or less
PAIN!
Acute Inflammation Bacterial infection of longer than 2 weeks
LOSS OF FUNCTION!
Chronic Inflammation
NO SYMPTOMS!
Persistent onslaught of bacteria
Exaggerated Host Inflammatory Response
NO SYMPTOMS!
Blood vessel
Tissues Complement activation
Macrophage
Bacteria Chemotaxis
Tissue damage Chemokines
PMN IL-1, IL-6, TNF-α IL-8
Prostaglandins Leukotrienes Macrophage Lymphocyte
Endothelial damage
Chapter 9
Host Immune Response to Periodontal Pathogens Section 1
The Role of Host Response in Periodontal Disease
158
Inflammatory Biochemical Mediators
Section 2
Pathogenesis of Inflammatory Periodontal Disease
160
Early Bacterial Accumulation Phase Early Gingivitis: Plaque Biofilm Overgrowth Phase Established Gingivitis: Subgingival Plaque Biofilm Phase Periodontitis: Tissue Destruction Phase Mechanisms of Bone Destruction
Section 3
Focus on Patients
169
Learning Objectives • Define the term immune system and name its primary function. • Examine the periodontium of a patient with gingivitis and point out the signs of inflammation that are visible in the tissues. • Define the term biochemical mediator and name three types of mediators. • Describe the tissue destruction that can be initiated by the biochemical mediators secreted by immune cells. • Describe the sequential development of periodontal disease. • Describe the role of the host response in the severity and tissue destruction seen in periodontitis. • Explain immunologic interactions of the host in periodontal diseases. • Describe and differentiate the mechanisms of tissue destruction in periodontal disease. • Describe and discuss current knowledge of the immunopathology of periodontal disease.
Key Terms Host response Host Biochemical mediators Cytokines
Prostaglandins Prostaglandins of the E series (PGE) Matrix metalloproteinases (MMPs)
Biofilm
IL-8 IL-1α PGE2 MMP TNFα
IL-8
CEJ Sulcus CDW
Junctional epithelium
Blood vessel
Bacteria
PMN
Biofilm
IL-8
IL-8 IL-1α PGE2 MMP TNFα
IL-1β IL-6 TNFα PGE2 IL-8
CEJ Sulcus
Blood vessel
CDW
Junctional epithelium
Bacteria
PMN
Macrophage
T-cell
Biofilm
IL-8 IL-1α PGE2 MMP TNFα
IL-8
MMP LT IL-1β IL-6 IL-8 TNFα
IL-1 TNFα
IgG IL-6 TNFα
IL-1α, β TNFα IL-8
Collagen MMP TIMP
CEJ
Blood vessel
Bacteria
PMN
PGE2 IL-10 IL-12 MMP
CDW
Gingival pocket due to swelling Junctional epithelium
IL-1β IL-1ra IL-6 TNFα
Macrophage
T-cell
B-cell
Plasma cell
Fibroblast
Biofilm
IL-1α, β TNFα IL-8 IL-1β IL-6 IL-8 TNFα
IL-8 IL-1α PGE2 MMP TNFα
MMP IL-8 IL-1β IL-1ra IL-6 IL-10 IL-12
Collagen MMP TIMP
CEJ
TNFα PGE2 MMP
Periodontal pocket
Bacteria
PMN
CDW
Junctional epithelium
Blood vessel
IL-1β IL-6 IL-8 TNFα
Macrophage
T-cell
B-cell
Plasma cell
Fibroblast
Macrophage
IL-1β
TNFα TNFα IL-1β
Fibroblast
MMP
MMP
PGE2
PGE2
Osteoclast
Extracellular matrix
Alveolar bone
Chapter 10
Systemic Factors Associated with Periodontal Disease Section 1
Systemic Risk Factors for Periodontitis
173
Diabetes Mellitus Leukemia Acquired Immunodeficiency Syndrome Osteoporosis Hormonal Variations
Section 2
Genetic Risk Factors for Periodontitis
182
Section 3
Systemic Medications with Periodontal Side Effects
186
Focus on Patients
191
Section 4
Learning Objectives • Describe systemic factors that may modify or amplify the host response to periodontal pathogens. • In the clinical setting, for a patient in your care with periodontitis, explain to your clinical instructor the risk factors that may have contributed to your patient’s periodontitis. • Define the terms Type I diabetes, Type II diabetes, and gestational diabetes. • Discuss the implications of diabetes on the periodontium. • Define the term osteoporosis and discuss the link between skeletal osteoporosis and alveolar bone loss in the jaw. • Discuss how hormone alterations may affect the periodontium. • Define the term pregnancy-associated pyogenic granuloma. • Explain how abnormalities of polymorphonuclear leukocytes may affect the body’s response to periodontal pathogens. • Describe the genetic and physical characteristics of Down syndrome. • Discuss the implications of Down syndrome on the periodontium. • Define the term drug-influenced gingival enlargement. • Name three medications that can cause gingival enlargement.
Tissue destruction
Enzymes elastase/collagenase/β-glucuronidase
Cytokines IL1, TNFα
PMNs
Monocyte/macrophage stimulation
Impaired chemotaxis
Chronic hyperglycemia
Advanced glycation end products
Reduced migration
Capillary thickening
Altered connective tissue fibroblast/osteoblast
Impaired host defenses
Poorer healing
Chapter 11
Smoking and Periodontal Disease Introduction to Smoking and Periodontal Disease
196
Mechanisms of Periodontal Disease Progression in Smokers
198
Section 3
Smoking Cessation
200
Section 4
Focus on Patients
205
Section 1 Section 2
Learning Objectives • Discuss the implications of smoking on periodontal health status. • Discuss the implications of smoking on the host response to periodontal disease. • Discuss the effects of smoking on periodontal treatment outcomes. • Discuss current theories as to why smokers have more periodontal disease than nonsmokers. • Explain why tobacco cessation counseling is a valuable part of patient care in the dental setting. • Value the importance of providing tobacco cessation counseling as a routine part of periodontal treatment.
Key Term Ask. Advise. Refer. Model for tobacco cessation counseling
A
B
Pack-year
40 30 20 10 0
